I have the modem attachment on my BiPAP that allows the DME to monitor my compliance. BCBS requires 3 months of use and in the last month, you have to be using it at least 4 hours per day. I'm not having a problem with being compliant. I don't have a problem with the insurance company wanting to make sure that I'm using it. Mostly because as a transcriptionist, I know that I need this machine and so I have to make it work if I want the quality of life that I want.
One of the clinics I transcribe for is a low-income clinic. I regularly hear doctors dictating about noncomplaint OSA patients. They run the gamut from people who refuse the sleep studies, people who got the first study and not the second, people who had the second study but give up on the machine almost immediately, and people who try for a while and give up.
In the county this clinic is located, there is a county health plan that low-income people can qualify for. It fills the gap between Medicaid and people who have or can afford coverage consisting of those folks who make too much money for Medicaid but can't afford to buy coverage. There is a limited benefit for durable medical equipment of only $250 per year, but there are also referrals to local agencies that provide low-cost or free medical equipment.This clinic is good at trying to get people the care they need and they have patient advocates to help people get on the county health plan. It's not the greatest healthcare, but it's better than nothing.
Yet, there are still noncompliant patients. They are noncompliant for lots of different reasons. Being low income poses more problems than just not having insurance. Transportation is also a problem. People don't fill prescriptions because they can't get to the drug store. They don't show up for appointments because they have no way to get to them. One patient didn't follow up on a cancer screening that showed she needed a biopsy because her phone broke and she had no way of getting her messages off her voicemail. She had no money to replace the phone. She never heard the message telling her to schedule the biopsy. That was more than a year ago. She finally went back to the clinic because she had another problem.
They also don't get the medication they need because the insurance company won't cover what the doctor prescribes. So by the time the doctor finds this out, the patient has been without medication for weeks or months.
Our insurance just changed from really really good coverage to slightly better than average coverage. Since then, we've been struggling to get my husband's Pristiq for two months now. The paperwork has been filed with the prescription insurance to make an exception for this medication because my husband has "failed" more than one antidepressant. This one works. It's not on formulary. There is no generic yet. If the doctor's office was not able to provide samples, he would have been without this medication for the past two months. The paperwork was filed over a month ago. Yet the exception has not come through yet. Clearly this medication works, so why don't they get off their cans and let him have it? Grrr...
In addition, they will NOT cover my Synthroid because it is not generic. In spite of the fact that my endo wants me on Synthroid because I have no thyroid (removed because of cancer) and Synthroid has been proven to have the steadiest dose. Generics vary widely in their dosage and you can't tell which company's generic you will get from your pharmacy...it all depends on who gives them the best price on their order. The one time I took a generic, too, it didn't work. I started becoming hypothyroid. My joints started freezing up and my fatigue was incredible. I need the brand name. But they won't cover it. I pay out of pocket for it now. Luckily, it's not a hugely expensive medication and luckily, I also found needymeds.org. I printed off their card and using it brought the cost of my medication down to almost what it was on insurance before. I highly recommend their site for anyone wanting to discover ways of affording their medication. GoodRX.com is another good site for helping with medication costs.
My husband also now has to take MORE of one of his meds that just went generic because the generic doesn't work as well as the brand name. But he can't get the brand name anymore because the insurance will not cover brand names if there is a generic available. If the generic isn't as good, how does this save them money? The price goes up as the dosage goes up per capsule, generally, at least for this medication. So now he has to take MORE generic pills to get the same effect he got on fewer name-brand pills. This isn't saving them much money, but this is the way this system works. The primary driving factor of this program is not patient care. It's how to save the system money.
I'm not fond of our insurance system. I think it fails a lot of people. But I don't know that anything that any government agency would enforce would fix it. Most hospitals have learned to work the Medicare system so well that they are bilking the government out of millions of dollars. In proof, I give you the Happy Hospitalist's blog:
http://thehappyhospitalist.blogspot.com ... tions.html
So expanding this system to include everyone? eh...I don't know. All I am sure of is that instead of everyone getting good insurance, what it will probably guarantee is that everyone will have really mediocre to really crappy insurance instead. And getting the drugs you need will be more of the same kind of struggle we are having now. Getting your CPAP covered may also become a struggle. After all, once the government decides that a brick is all they want to pay for, a brick is all we will be able to get except for people who can afford to pay out of pocket. So this doesn't level the playing field. People with money will still get better care. Everyone else will get the bare basics. And without transportation, without money to pay the phone bill, without being able to get the medication they really need or get in for surgery without getting on a waiting list, are patient outcomes really going to improve?
